Serious case review

LINCOLNSHIRE SAFEGUARDING ADULTS BOARD SERIOUS CASE REVIEW In respect of X (deceased) (Died 6 September 2006) EXECUTIVE SUMMARY 30 November 2009 INTRODUCTION X had Epilepsy and Autism Spectrum Disorder (ASD). His family home was in Nottingham, but his parents took the decision that he would be better cared for in specialist accommodation. Accordingly, during 1996 he became resident at a specialist residential unit in Lincolnshire.
Following several seizures in 2006 his usual prescribed medication (Epilim) was supplemented by Keppra. Keppra should have been administered twice each day at 9am and 9pm. On Saturday 2 September 2006 night staff completed an entry in a handover/communication book indicating that X was about to run out of Keppra. No immediate steps were taken to obtain further supplies and records show that at 2100 on Sunday 3 September 2006 X had his last dose of Keppra. At 0910 on Wednesday 6 September 2006 he was found dead in bed. By this time he had missed four doses of Keppra and had been due a fifth at 0900 that day.
An inquest jury later concluded that the failure to provide Keppra had materially contributed to his death. The jury also decided that systemic failures in relation to stock keeping, record keeping, and a lack of sufficient training, communication and vigilance by staff to follow policy and procedures had all contributed to the death. PROCESS

On 15 May 2008, the Lincolnshire Safeguarding Adults Board agreed that an independently chaired Serious Case Review should be commissioned. The review terms of reference were:
To examine the circumstances leading up to the death of X with a view to establishing:
Whether there are lessons to be learned about the way in which professionals and others involved in the case worked together to protect X.
Whether policies and procedures applying to the placing and host Adult Social Services authorities were correctly followed.
Whether arrangements for Adult Protection Case Conferences involving a number of placing and a host authority require review.
Based on the findings of the inquest and the result of the Serious Case Review, identify individual and systemic issues which may have contributed to treatment of X falling short of expected standards and make recommendations to inform action plans aimed at overcoming these.
FINDINGS Policy and Procedures at the Residential UnitThe serious case review panel were provided with extensive documentation by the management of the unit and also took account of evidence provided at the Coroners Inquest. Having considered information from these sources the panel identified failings in relation to staff qualifications, management, supervision and training. It was also clear that communication between management and across staff teams was poor or not appropriately responded to. This resulted in staff closely involved in the care of X failing to correctly follow policy and procedures and in turn brought about the lack of an adequate and safe service to X (Recommendations 1-5). Lessons to be learned about the way in which professionals and others involved in the case worked together to protect X
The review panel found that professionals and others did not always work well together to protect X. Problems were identified in the regulatory system governing the operation of the unit. Resources applied to the inspection and monitoring of activity were not sufficient to be able to rely on the findings of Commission for Social Care Inspection (now CQC) and local authority quality assurance processes. Examples of this include failures to discover that National Minimum Standards were not adhered to or that Department of Health Circular (LAC 93(7) had not been followed by placing and host authorities. In fact, the review panel reached the conclusion that across the country LAC 93(7) is almost routinely ignored. Joint yearly reviews of the suitability of X’s treatment at the unit had not been conducted each year by the placing and host authorities. The review panel came to the view that the use of the terms ‘Requirement’ and ‘Recommendations’ within CQC Inspection Reports may be misleading to the general public. CQC inspection reports are available to the public and are a valuable source of information when seeking a suitable and safe care home in which to house loved ones. It is therefore critical that inspection reports and other monitoring activity provide accurate information on which to base such decisions (Recommendations 6 -13).

Events after 6 September 2006

At the time of the death there were three residents from within Lincolnshire at the unit and because the police investigation was given precedence these service users were not promptly risk assessed. Service users from outside Lincolnshire were not risk assessed because placing authorities and self funding residents (total about 30) were not formally informed of events until other local authorities were contacted inviting attendance at an adult protection strategy conference in May 2007. Although criminal investigations should be given precedence there is no reason why information should not be shared to safeguard vulnerable adults and a multi agency investigation for this purpose commenced at an early date.
Seven representatives of local authorities outside Lincolnshire attended the May 2007 meeting and eight sent apologies. At the later case conference meeting one representative from another authority was present but nine others did not respond to invitations. The parents of X have indicated that they were not contacted to discuss process and timescales or made aware of developments until they were contacted and asked to contribute views to the serious case review. This served to aggravate an already distressing situation and is not acceptable. When the Serious Case Review commenced, letters were sent to all placing authorities asking for comments on their placements at the unit (to include a negative response). Very few responses were received. It is in the interests of all local authorities placing service users in other areas to cooperate with serious case reviews. If thorough reviews are not carried out other vulnerable adults are likely to be needlessly placed in danger. The Department of Health is currently conducting a review of ‘No Secrets’. Part of that review is looking at whether participation in adult safeguarding serious case reviews should be made mandatory. (Recommendations 14-20).

RECOMMENDATIONS Recommendation 1 The unit’s management should ensure that senior on site management take responsibility for ensuring that middle level management and more junior staff perform their roles in line with company policy and procedures. The fact that this responsibility cannot be passed to others should be made clear to those concerned. Recommendation 2 The unit’s management should ensure that managers and other supervisors at all levels have suitable qualifications linked to the key tasks expected of them. Recommendation 3 Newly appointed managers and other supervisors should be provided with suitable mentoring and personal development plans and performance should then be monitored to provide evidence of achievement.

1 No Secrets: guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse (London: DH2000). Recommendation 4 The unit’s management should ensure that all staff receive the required levels of supervision and that issues raised are responded to in an appropriate manner and decisions on any required changes recorded. If management decide that no action is necessary in relation to issues raised staff should be informed of the decision and its rationale. Recommendation 5 The unit’s management should ensure that all staff employed in a capacity where they are likely to be involved in the administration of anticonvulsant and other prescribed medication are aware of the purpose of the medication and the importance of administering it to service users in line with medical advice. Recommendation 6 The DH may wish to consider reinforcing the contents of Local Authority Circular 93(7) and place increased emphasis on compliance with its contents, in particular that the duty of placing local authorities to inform host authorities of placements, must be complied with. Recommendation 7 Lincolnshire County Council Adult Social Care Department should consider whether the staffing and terms of reference of the Quality Assurance Team should be reviewed, so that in future similar problems to those revealed at the unit would be more likely to be identified and tragedies such as the death of X averted. Recommendation 8 Nottingham City Council Adult Social Care Services should ensure that when service users are placed in other Local Authority Areas, correct procedures are followed and the host authority informed of the placement. Recommendation 9 Nottingham City Council Adult Social Care Services should ensure that yearly reviews of placements within other authorities take place and that information from the host authority forms a part of the review of care arrangements. Recommendation 10 Lincolnshire County Council Adult Social Care Department should consider how to ensure that proper information exchange takes is achieved between host and placing authorities to assist good and thorough care reviews at the unit and other similar care settings. Recommendation 11

The Care Quality Commission should seek consultations and review whether it is possible to remove the different approaches to resolving issues arising from the use of the terms Requirements/Recommendations in Inspection Reports. Recommendation 12

The DH may wish to consider whether National Minimum Standards should become legally enforceable. Recommendation 13 The Care Quality Commission may wish to consider providing sufficient resources to conduct detailed inspections of care provider settings. Alternatively it should be made clear on inspection reports and the Commission’s website that inspection reports provide a limited rather than detailed view on performance.

Recommendation 14 Lincolnshire Safeguarding Adults Board should ensure that in the event of a serious incident within a care setting multi agency procedures are promptly instigated with a focus on investigating adult safeguarding concerns and safeguarding other service users. Recommendation 15

Lincolnshire County Council Adult Social Care Department should ensure that where a serious incident within a residential care setting occurs, placing authorities are formally informed at an early date. A thorough assessment of risk should include the desirability or otherwise of also informing the families/carers of service users.

Recommendation 16

Lincolnshire County Council Adult Social Care Department and Nottingham City Council Adult Social Care Services should ensure that if service users suffer death or serious injury their families/carers should be contacted at an early stage, fully informed of the circumstances, provided with a named contact and thereafter kept up to date with ongoing developments. Recommendation 17

The DH may wish to consider circulating advice to Local Authorities reinforcing a duty to contribute to Adult Safeguarding Investigations and Case Conferences held outside their areas, but involving residents placed by them in that area.

Recommendation 18 Lincolnshire Safeguarding Adults Board should review its multi agency procedures to ensure that POVA list notifications are made as soon as practicable after a serious incident Recommendation 19 Lincolnshire Safeguarding Adults Board should ensure that decisions on whether to conduct a Serious Case Review are taken swiftly, if necessary outside its usual quarterly meeting cycle. Any review should be started promptly and steps taken to secure cooperation and information gathering from involved organisations/individuals. Recommendation 20

The Department of Health should consider whether the events described in this review require that legislation should enforce participation in serious case reviews by those holding relevant information. CONCLUSION On 18 June 2009 the Lincolnshire Safeguarding Adults Board accepted the above recommendations. The Board also agreed to bring the review report to the attention of the Department of Health and the Care Quality Commission so that recommendations relating to national policy might be considered at the appropriate level. An Action Plan was agreed and this will be reviewed to ensure recommendations are reviewed and implemented.
Finally I take this opportunity to thank review panel members and others contributing to this review. In particular I record my thanks to X’s parents who despite their great feeling of loss have treated me with every courtesy and provided detailed information to assist the review process. I formally express my condolences for the loss of a much loved son and the hope that this review might help bring some form of closure, in the knowledge that its recommendations may help avert similar tragedies. Roger Vickers Independent Adult Safeguarding Consultant Serious Case Review Panel Chair